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Lower step rate is associated with a higher risk of bone stress injury: a prospective study of collegiate cross country runners


Objectives To determine if running biomechanics and bone mineral density (BMD) were independently associated with bone stress injury (BSI) in a cohort of National Collegiate Athletic Association Division I cross country runners.

Methods This was a prospective, observational study of 54 healthy collegiate cross country runners over three consecutive seasons. Whole body kinematics, ground reaction forces (GRFs) and BMD measures were collected during the preseason over 3 years via motion capture on an instrumented treadmill and total body densitometer scans. All medically diagnosed BSIs up to 12 months following preseason data collection were recorded. Generalised estimating equations were used to identify independent risk factors of BSI.

Results Univariably, step rate, centre of mass vertical excursion, peak vertical GRF and vertical GRF impulse were associated with BSI incidence. After adjusting for history of BSI and sex in a multivariable model, a higher step rate was independently associated with a decreased risk of BSI. BSI risk decreased by 5% (relative risk (RR): 0.95; 95% CI 0.91 to 0.98) with each one step/min increase in step rate. BMD z-score was not a statistically significant risk predictor in the final multivariable model (RR: 0.93, 95% CI 0.85 to 1.03). No other biomechanical variables were found to be associated with BSI risk.

Conclusion Low step rate is an important risk factor for BSI among collegiate cross country runners and should be considered when developing comprehensive programmes to mitigate BSI risk in distance runners.

  • bone mineral density
  • biomechanics
  • running
  • injuries

Data availability statement

Data are available upon reasonable request. Requests for data sharing from appropriate researchers and entities will be considered on a case-by-case basis. Interested parties should contact Dr Heiderscheit (

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